Tardive dyskinesia in neuroleptic medicated mentally handicapped subjects

Sixty-seven neuroleptic medicated mentally handicapped subjects in a hospital were rated on two occasions for abnormal involuntary movements on three scales: Abnormal Involuntary Movements (AIMS), Rockland and Parkinsonism scales, with 6 months between each assessment. Inter-rater and test-retest reliabilities were high. The data from the second assessment was analyzed. Prevalence of tardive dyskinesia (TD) was 21% on AIMS, 42% on the Rockland scale; 60% had parkinsonism. Multiple stepwise regression analysis revealed that age, sex, current neuroleptic and anticholinergic dose, antiepileptic medication, psychosis, cumulative anticholinergic dose were not significant predictors of TD as determined by AIMS. Parkinsonism and cumulative neuroleptic dose were significant predictors of and correlated positively with AIMS score. TD subjects formed 35% of the parkinsonian group. Overt brain damage was not a significant predictor of AIMS score and the difference between the neuroleptic medicated and neuroleptic free group on AIMS scores was highly significant.     

Dyskinesia in mentally handicapped women: relationship to level of handicap,age and neuroleptic exposure

The prevalence of dyskinesia in a randomly selected set of 61 mentally handicapped women with a range of diagnoses, levels of IQ and exposure to neuroleptics was assessed using the Abnormal Involuntary Movements Scale (AIMS). Overall, 64% of patients had dyskinesia on the AIMS. There was no correlation with neuroleptic exposure, although 43% of patients had been significantly exposed. There was no correlation between the presence of dyskinesia and the original handicapping diagnosis, and there was no increase in dyskinesia as the patients age increased. There was a significant increase in dyskinesia as IQ fell. This study backs the contention that there is a close association between cognitive impairment and movement disorder.     

The single-word lexicon of a severely mentally handicapped child

Three criteria — phonetic form, semantic relevance and communicative saliency — are used to identify the single-word vocabulary of a young mentally handicapped child. The data are taken from video recordings made of the child playing at home and at school over a 12-month period. Inspection of the words reveals that the child exhibits phonological processes typical of younger, normally developing children and, when the complete vocabulary collected for this period is categorized following Nelson (1973), the proportion of word types used is comparable to those reported for normally developing children at the single-word stage. However. this child's use of single words is not restricted to the here-and-now but is used to transcend time and space.     

Dexamethasone suppression test and response to antidepressants in depressed mentally handicapped subjects

ABSTRACT. Nineteen mentally handicapped subjects who were referred to the service with clinically significant depression were assessed with a view to determining the value of the dexamethasone suppression test (DST) in clinical diagnosis and in predicting response to antidepressant treatment. They were assessed initially and then 3 months after they had been treated with a tricyclic antidepressant. It was found that a significant proportion had an abnormal DST response which reversed after recovery in some but not in others. Non-reversal was more likely to occur in the more severely handicapped patients. It was concluded that DST was of little value as a diagnostic tool for the detection of depression in mentally handicapped subjects.     

Factors associated with discontinuation of long-term lithium treatment

Sixty-four outpatients with major affective disorder according to DSM-III and on continuous lithium treatment for an average duration of 7.8 years were first investigated in 1980 and then followed for 7 years. The predictive value of patients' attitudes to their lithium, the prognostic influence of psychiatric status, side effects, and anamnestic and laboratory data including lithium parameters were studied. At the end of the 7-year follow-up, 61% of the patients were still on lithium maintenance treatment, 25% had discontinued lithium for clinical reasons, and 14% of the patients had died. Side effects of lithium were the major clinical reason for discontinuing treatment, while attitudes towards medication were of minor importance. Approximately one fourth of the patients who discontinued lithium were differentiated from those who continued treatment by showing a high frequency of the neurologic side effects incoordination, paresthesia, and disturbed sensibility in addition to having more severe tremor. In yet another fourth of those who discontinued for clinical reasons, lithium was stopped by the treating psychiatrist as maximal urine osmolality values were considered to be too low. These patients did not show any signs of clinically significant impairment of renal functions. Their psychiatric status was excellent in terms of extremely low CPRS scores. The patients who died during the follow-up period were differentiated from those who continued treatment by a much higher frequency of alcohol and drug abuse prior to the initiation of lithium therapy. The total number of side effects and the number of severe side effects were significantly larger than in continuers on lithium. The most common causes of death were cardiovascular disease and suicide. In no case was the cause of death attributed to lithium therapy.     

Therapeutic intervention in mentally retarded adult epileptics

Clinical features of epilepsy, especially those connected with drug therapy, were evaluated for mentally retarded adult epileptics who were admitted to the neurological out-patient unit during 1977-83. These features were re-evaluated in 1985 and compared with findings from the first visit. During follow-up, the type and frequency of seizures were determined and if possible, medical therapy was either concluded or changed. The therapeutic intervention resulted in the use of fewer and less toxic drugs, for which the serum concentrations were more often within recommended ranges. These aspects may be due to the significant decrease in seizure frequency observed. In order to provide patients with the most efficacious therapy, the therapeutic needs of mentally retarded adult epileptics should be evaluated by a neurologist familiar with epilepsy.     

Problems with the use of conventional anticonvulsant drugs in mentally retarded individuals

Special problems in the use of anticonvulsant agents in the mentally retarded are reviewed. Effects of barbiturates on mental abilities and of phenytoin on facial appearance are especially undesirable side effects of these agents in mentally retarded individuals. Careful consideration should be given to selection of anticonvulsants that minimally interfere with the long-term rehabilitation of mentally retarded persons. The relationship of paroxysmal EEG abnormalities, episodic violence and hysteroepilepsy to epilepsy is discussed.     

Kidney function and response to lithium treatment

1. Kidney function during long-term lithium treatment was studied in the representative sample of patients with recurrent affective disorders. Creatinine clearance, maximum urinary osmolality and 24-hour urine volume were determined. 2. Patients were divided according to their type of response to long-term lithium treatment, expressed by the effect on the frequency of recurrencies. Various indicators of kidney function were compared in excellent responders and in non-responders. 3. Long-term lithium treatment did not lead to any detectable changes of glomerular filtration in either group. 4. In comparison with responders, non-responders showed a significantly greater increase in 24-hour urine volume and a trend towards a greater reduction of maximum urinary osmolality, and thus a greater impairment of tubular function. 5. The findings stress the need for a careful selection of patients for long-term lithium stabilization.     

Persistent cognitive deficits associated with lithium intoxication: a neuropsychological case description

We present the case of a 51-year-old patient with an acute lithium intoxication associated with several cognitive deficits. During the acute phase of intoxication the patient displayed general psychomotor slowing, dysarthric speech, mood changes, and incoherent discourse. Neuropsychological assessment revealed ideomotor apraxia, profound deficits of visuospatial processing, an impairment of memory and of frontal-executive functions. Other cognitive abilities, such as orientation, spontaneous speech, comprehension, naming, reading, writing, and working memory remained intact. An electroencephalogram revealed diffuse slowing with rhythmic trains, whereas MRI showed no cerebral abnormality. Follow-up examinations at 4 and 14 weeks with lithium levels in the normal range showed substantial recovery of memory abilities and executive functions, whereas praxis and visuoperceptual functions remained impaired, despite the fact that lithium was immediately withdrawn after the intoxication became manifest. We conclude that lithium intoxication may be associated with variable behavioural and cognitive impairments, some of them potentially persistent. Different from other case studies our findings suggest that lithium intoxication may cause a combined, multifocal functional impairment of subcortical and cortical neural mechanisms in both hemispheres.     

Factors associated with lack of response to valproic acid monotherapy in juvenile myoclonic epilepsy

PurposeTo determine factors associated with lack of response to valproic acid (VPA) in juvenile myoclonic epilepsy (JME).MethodRetrospective analysis of clinical and EEG data of 201 patients with JME who had at least 3 years follow up was performed. Psychiatric evaluation was performed using ICD-10 by structured clinical interview. Patients were divided into two groups: VPA responders (seizure free for 2 or more years) and those with lack of response to VPA. Effect size for non-response and correlations for variables significantly different between the groups was performed, the findings were confirmed by ROC curves.ResultsThe mean duration of follow up was 7.75 (range 3–12) years; 55.2% were males. Focal semiologic features were noted is 16%. EEG was abnormal in 67%; focal EEG abnormalities were noted in 32.8%. Coexisting psychiatric disorders (PDs) were found in 33.3%. Lack of response to VPA was noted in 19%. Diagnosis of PDs and focal EEG abnormalities significantly increased the risk of VPA non-responsiveness by 5.54 (95% CI of 2.60–11.80; p < 0.0001) and 3.01 times respectively (95% CI of 1.40–6.47; p < 0.008). Diagnosis of PDs showed significant correlation (r = 0.332; p < 0.0001) and association (AUC 0.700; p < 0.0001) with lack of response to VPA. Though focal EEG abnormalities increased the chances, it did not correlate with lack of response to VPA.ConclusionLack of response to VPA was noted 19% of patients with JME. Coexisting PDs showed significant correlation and association with lack of response to VPA.     

Factors associated with response to lithium prophylaxis in DSM III major depression and bipolar disorder

The relationship of some clinical, personality and biological variables to the outcome of lithium prophylaxis was investigated in two patient samples fulfilling, respectively, the DSM III definitions of "major depression, recurrent" and "bipolar disorder". In major depressives, the presence of psychomotor retardation and melancholia during the index episode was associated with a favorable response to treatment, whereas the presence of mood-incongruent psychotic features during the same episode, a high score on the "anxiety" and "phobic" subscales of the Middlesex Hospital Questionnaire and a high score on the "neuroticism" subscale of the Eysenck Personality Questionnaire were related to a poor response. These findings are discussed in the light of the heterogeneity of DSM III major depression and of the reported common occurrence of an "anxiety-phobic" personality profile in unipolar depressives. In bipolar patients, a family history of bipolar affective illness and a high lithium ratio were associated with a good response to treatment, and the presence of the HLA-A3 antigen with an unfavorable response. These findings seem to support a role of pharmacogenetic factors in conditioning response to lithium prophylaxis.     

RBC-choline: changes by lithium and relation to prophylactic response

ABSTRACT– Red blod cell (RBC)- and plasma-choline levels were measured in patients on lithium (n= 96), antidepressants (n - 32) and nenroleptics (n= 51), and in 25 healthy drug-free controls. Lithium patients exhibited highly increased RBC- and slightly increased plasma-choline levels compared with controls (P < 0.001 and P < 0.05, respectively); the choline ratio (RBC-/plasma-choline) was elevated almost to the same extent as RBC-choline (P < 0.001). With antidepressants RBC-choline and choline ratios were slightly reduced (P < 0.05), whereas neuroleptics showed no effect on choline levels. 79 % of lithium patients were responders (reduction in hospitalizations with lithium), 21 % were non-responders (no reduction or increase in hospitalizations]. Choline ratio exhibited a significant relation to prophylactic lithium response, but lithium ratio did not. The percentage of nori-responders was significantly higher in patients with a choline ratio exceeding 100 than in patients with a choline ratio below this cut-off (P < 0.01). Thus, the increase of RBC-choline and choline ratios appears to be an effect specific for lithium and might be related to the outcome of lithium prophylaxis.     

Facing stress and conflict: a comparison of the predicted responses and self-concepts of aggressive and non-aggressive people with intellectual disability

The present research consisted of two studies. A total of 44 participants were involved in the first study: 22 individuals with problems of aggression (Ag) and 22 non-aggressive (NAg) individuals. A sentence completion test was used to explore whether there were differences between the two groups' predicted coping responses in stressful situations. While the Ag group provided most aggressive responses, the NAg participants were more assertive. However, gender differences also emerged, with women proving to be less aggressive. A high number of passive answers were given across all the groups, suggesting that background experience could have influenced the participants' sense of efficacy in stressful situations. In the second study, a subsample of the participants were interviewed. The aim was to explore whether particular background experience coloured their perceptions of self and others, in situations of conflict. While nine out of the 10 Ag participants described incidents where they felt treated in a derogatory manner which could be linked to their disability, only two out of the nine NAg participants felt slighted in this fashion. Hence, a vulnerable sense of self could contribute to greater sensitivity in interpersonal situations, increasing the likelihood of an aggressive response. The clinical relevance of this work is discussed, alongside the possibilities for future research in this area.     

Differences in cortisol response affect the distinction of observed reactive and proactive aggression in children with aggressive behaviour disorders

Summary. Various researchers distinguished two categories of aggressive behaviour, namely reactive and proactive aggression. Reactive aggression is an aggressive response to a perceived threat or provocation, whereas proactive aggression is behaviour that anticipates a reward. In the present study, including both a sample of disruptive behaviour disordered (DBD) and normal control (NC) children, we observed reactive and proactive aggressive behaviour during an experimental dyadic play session. DBD children showed more observed reactive and proactive aggression. Subsequently, we investigated whether the observed measures correlated with parent-rated measures of reactive and proactive aggression in. We distinguished in both NC and DBD children a subgroup showing a rise in cortisol level, i.e. responders, and a subgroup who did not show a rise in cortisol, i.e. non-responders. Results suggest that differences in the cortisol response affects the correspondence between observed and parent-rated reactive and proactive aggression since only DBD non-responders showed the expected correlations. Correspondence: Maaike Kempes, Department of Child and Adolescent Psychiatry, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, PB 85500, Hpnr.B01.324, Utrecht, The Netherlands